Improving blood flow in occluded veins to reduce anti-vascular endothelial growth factor injections for branch retinal vein occlusion

Purpose

To assess the relationship between improving blood flow via arteriovenous (AV) sheathotomy without vitrectomy and the total number of anti-vascular endothelial growth factor injections (VEGF) required to treat branch retinal vein occlusion (BRVO).

Methods

In this prospective, clinical case series, 16 eyes of 16 patients at the Toho University Sakura Medical Center with best-corrected visual acuity (BCVA) of 20/40 or worse due to macular edema associated with BRVO were analyzed for 12 months. AV sheathotomy was performed without vitrectomy for all cases. On the second day after surgery, anti-VEGF was injected into the operated eye. During the 12-month follow-up after surgery, pro re nata injections were administered when changes in foveal exudation and BCVA were evident. The blood flow of the occluded vein was assessed before and after AV sheathotomy during the operation using laser speckle flowgraphy. The total number of anti-VEGF injections, central retinal thickness (CRT), and BCVA 12 months after surgery were examined.

Results

The changes in CRT and BCVA from baseline to month 12 were statistically significant (P < 0.01). No additional anti-VEGF injections were required for nine of 16 eyes (56.3%) during the 12 months. The total number of anti-VEGF injections for 12 months correlated with the change rate of blood flow in an occluded vein before and after AV sheathotomy (r = -2.816, P = 0.022).

Conclusions and Importance

Improved blood flow in occluded vein may reduce the need for anti-VEGF injections in BRVO.

Real-Life Efficacy of Bevacizumab Treatment for Macular Edema Secondary to Central Retinal Vein Occlusion according to Pro Re Nata or Treat-and-Extend Regimen in Eyes with or without Epiretinal Membrane

Purpose. To present real-life data of patients with macular edema (ME) secondary to central retinal vein occlusion (CRVO) treated with bevacizumab (BVZ); determine the possible influence of epiretinal membrane (ERM) on treatment efficacy; and compare treatment outcomes in a treat-and-extend regimen (TER) versus pro re nata (PRN). Methods. We carried out a retrospective analysis of 58 eyes (56 patients) with new-onset CRVO treated only with intravitreal bevacizumab according to TER or PRN. Outcome measures were best-corrected visual acuity (BCVA) and central retinal thickness (CRT) at baseline and 12 months after the first treatment, number of visits and injections, and presence of ERM confirmed by optical coherence tomography in the first 6 months. Results. At 12 months, the mean number of injections was 6.3 across all eyes, with significantly more injections given in TER ( $p<0.001$ ). Mean CRT improved from 627 μm to 359 μm ( $p<0.001$ ) in all eyes, with improvement noted in TER ( $p<0.001$ ), PRN ( $p<0.001$ ), ERM ( $p=0.003$ ), and non-ERM ( $p<0.001$ ) subgroups. The mean BCVA gain was +13.6 letters, and the mean BCVA improved from 0.81 to 0.54 LogMAR ( $p<0.001$ ) in all eyes. BCVA improvement from baseline was significant in TER ( $p<0.001$ ) and non-ERM ( $p<0.001$ ) but not in PRN ( $p=0.08$ ) or ERM ( $p=0.2$ ) subgroups. Seven eyes, all receiving PRN treatment, developed neovascularization. Conclusions. Intravitreal bevacizumab according to either PRN or TER resolved edema and stabilized vision in the first 12 months, with TER yielding significant visual improvement and avoiding neovascular complications. ERM had no influence on bevacizumab efficacy in reducing ME in CRVO during 12 months of treatment.

Macular and choroidal thicknesses in a healthy Hispanic population evaluated by high-definition spectral-domain optical coherence tomography (SD-OCT)

Purpose

To report normal values of macular and choroidal thickness obtained from a healthy Hispanic population using Optovue (Optovue Inc, Freemont CA, USA) spectral domain optical coherence tomography (SD-OCT).

Design

Observational, cross-sectional, correlation study.

Methods

A total of 290 eyes (145 healthy subjects) were included; 69% of subjects were female. The median age was 39 ± 29 years (IQR), with a range between 18 and 89 years. The study sample was stratified into three age groups: Group 1, 18–40 years (50.3%), Group 2, 41–60 years (30.7%), and Group 3, older than 61 years (19%). Central macular, perifoveal (inner quadrants), and parafoveal (outer quadrants) thicknesses were estimated. In addition, central and peripheral choroidal thicknesses were estimated. Data analysis was performed to calculate the standardized mean difference according to the variance (Student’s t-test) and its differences with Epidat 4.1.

Results

Median macular central thickness was 250 ±30 µm (IQR) with Optovue. Median central choroidal thickness was 263 ± 48 µm (IQR). Median central choroidal thickness was greater than mean peripheral thickness. Macular evaluation showed a statistically significant difference in central, perifoveal, and parafoveal thicknesses, with lower values being recorded for the study sample compared with the manufacturer’s data.

Conclusions

SD-OCT has become a useful tool to obtain high-resolution images of the macula and choroid. This method allows precise assessment of the retinal and choroidal layers to diagnose and follow up posterior segment diseases. We are reporting normal cut-off values of macular and choroidal thicknesses in healthy Hispanic subjects evaluated with Optovue SD-OCT as new diagnostic normal parameters for research and clinical activities.

Clinical presentation and prognostic factors affecting surgical outcomes of secondary macular holes after retinal vein occlusions

PURPOSE

To describe clinical presentation, morphological features and surgical outcomes of macular hole (MH) secondary to retinal vein occlusion (RVO).

METHOD

This prospective interventional study evaluated eight eyes with atypical MH (secondary to RVO) and data regarding medical management, pars plana vitrectomy, postoperative anatomical hole closure, visual acuity improvement, morphological features of hole were noted till the last follow-up.

RESULTS

Eight eyes with full-thickness MH in an RVO eye were followed-up for a minimum period of 3 months postoperatively. Five subjects had a RVO episode which occurred more than 6 months before the onset of the recent symptoms (Group 1; 4 branch RVO and 1 central RVO), and 3 subjects had a recent onset branch RVO within 6 months (Group 2). All FTMH cases except one showed closure at the last follow-up. Visual acuity of all eyes improved from 0.91 ± 0.57 logMAR to 0.5 ± 0.3 logMAR (p = 0.093). At baseline, visual acuities of the two groups had no significant difference. Postoperatively, group 1 holes had better visual prognosis, than Group 2 holes, further substantiated by persistence of subretinal fluid in Group 2 eyes till last follow-up. Minimum hole diameter was higher in the recent RVO group, although anatomical closure was obtained in all of these eyes. Most holes had favorable morphological hole features like raised configuration with rounded edges.

CONCLUSION

In the presence of favorable morphological features, secondary macular holes associated with retinal vein occlusion may show optimal outcomes after surgery. It is not clear whether acutely created holes in recent onset RVO should be operated early. Older holes may have better prognosis.

Rebound Phenomenon after Intravitreal Injection of Triamcinolone Acetonide for Macular Edema

INTRODUCTION

The aim of this article was to report on a rebound phenomenon after intravitreal triamcinolone acetonide (IVTA) injection for macular edema secondary to diabetic retinopathy (DR) and central or branch retinal vein occlusion (CRVO/BRVO).

METHODS

The data were analyzed retrospectively. Complete ophthalmic examinations, including spectral domain optical coherence tomography, were performed before and 2 months after IVTA injection. The incidence of a rebound phenomenon was defined as an increase in central retinal thickness of >10% from baseline at 2 months after IVTA injection.

RESULTS

This retrospective study included 211 consecutive patients (268 eyes). One hundred ninety (71.2%), 39 (14.6%), and 39 (14.6%) eyes had macular edema (ME) due to DR, CRVO, and BRVO. In total, 9.7% of the eyes showed a rebound phenomenon (DR: 9.5%, CRVO: 5.2%, BRVO: 15.4%). The mean number of prior injections of vascular endothelial growth factor inhibitor or corticosteroid agent was statistically significantly higher in the rebound group (6.8 vs. 5.3) than in the nonrebound group (p = 0.01).

CONCLUSION

Our study shows that 9.7% of the eyes with ME secondary to DR and RVO developed a rebound phenomenon following IVTA injection, limiting its therapeutic effect. We found an increased number of prior intravitreal pharmacotherapy to be a risk factor for a rebound phenomenon.

RETINAL VASCULAR CYSTOID MACULAR EDEMA: Review and New Theory

: Retinal vascular disease has the potential to affect hundreds of millions of people, with the inherent risk of vision loss related to cystoid macular edema. Although there have been histologic evaluation of eyes having cystoid macular edema, the most recent paper was published more than 30 years ago. In retinal vascular cystoid macular edema fluorescein angiography, a modality that images the superficial vascular plexus, shows increased leakage. Optical coherence tomography angiography has provided unprecedented resolution of retinal vascular flow in a depth resolved manner and demonstrates areas of decreased or absent flow in the deep vascular plexus colocalizing with the cystoid spaces. There has been a large amount of research on fluid management and edema in the brain, much of which may have analogues in the eye. Interstitial flow of fluid as managed by Müller cells may occur in the retina, comparable in some ways to the bulk flow in brain parenchyma, which is managed by astrocytes. Absent blood flow in the deep retinal plexus may restrict fluid management strategies in the retina, to include transport of excess fluid out of the retina into the blood by Müller cells. Application of this theory may help in increasing understanding of the pathophysiology of retinal vascular cystoid macular edema and may lead to new therapeutic approaches.

Pars Plana Vitrectomy Combined with Internal Limiting Membrane Peeling to Treat Persistent Macular Edema after Anti-Vascular Endothelial Growth Factor Treatment in Cases of Ischemic Central Retinal Vein Occlusion

OBJECTIVE

To evaluate the efficacy of pars plana vitrectomy (PPV) combined with internal limiting membrane (ILM) peeling in cases of ischemic central retinal vein occlusion (CRVO) where macular edema (ME) persisted after anti-vascular endothelial growth factor (anti-VEGF) treatment.

METHODS

Fifteen eyes with ischemic CRVO-related ME were included in the study. Nine were treated with panretinal photocoagulation after initial examination. Anti-VEGF agents were injected intravitreally. Persistent ME was treated with PPV combined with ILM peeling. During surgery, laser photocoagulation was further applied to the non-perfused area.

RESULTS

Mean retinal thickness gradually decreased after surgery (p = 0.024 at 6 months), although visual acuity did not improve significantly during the follow-up period (14.7 ± 11.6 months). Neovascular glaucoma subsequently developed in three cases and a trabeculectomy was performed in one case.

CONCLUSION

In eyes with ischemic CRVO, PPV combined with ILM peeling contributed to a reduction in persistent ME. However, there was no significant improvement in visual acuity.

Intravitreal steroids versus observation for macular edema secondary to central retinal vein occlusion

BACKGROUND

Central retinal vein occlusion (CRVO) is a common retinal vascular abnormality associated with conditions such as hypertension, diabetes, glaucoma, and a wide variety of hematologic disorders. Macular edema (ME) represents an important vision-threatening complication of CRVO. Intravitreal steroids (IVS), such as triamcinolone acetonide, have been utilized to treat macular edema stemming from a variety of etiologies and may be a treatment option for CRVO-ME.

OBJECTIVES

To explore the effectiveness and safety of intravitreal steroids in the treatment of CRVO-ME.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2014 Issue 10), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to November 2014), EMBASE (January 1980 to November 2014), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 13 November 2014. For all included primary studies, we used The Science Citation Index (3 December 2014) and manually reviewed reference lists to identify other possible relevant trials.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that compared intravitreal steroids, of any dosage and duration of treatment of at least six months, with observation for the treatment of CRVO-ME.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts identified from the electronic searches and assessed full-text articles from potentially eligible trials. Two review authors independently assessed trial characteristics, risk of bias, and extracted data from included trials. We contacted investigators of included trials for desired data not provided in the trial reports.

MAIN RESULTS

We included two RCTs that enrolled a total of 708 participants with CRVO-ME. SCORE compared triamcinolone acetonide intravitreal injections (n = 165) with observation (n = 72); GENEVA compared dexamethasone intravitreal implants (n = 290) with sham injections (n = 147). We observed characteristics indicative of high risk of bias due to incomplete outcome data in SCORE and selective outcome reporting in GENEVA. Loss to follow-up was high with 10% in the steroid groups and almost twice as much (17%) in the observation group. GENEVA enrolled participants with both branch and central retinal vein occlusion, but did not present subgroup data for the CRVO-ME population. A qualitative assessment of the results from GENEVA indicated that the dexamethasone implant was not associated with improvement in visual acuity after six months among participants with CRVO-ME. Although the SCORE investigators reported that participants treated with 1 mg (n = 82) or 4 mg (n = 83) triamcinolone intravitreal injections were five times more likely to have gained 15 letters or more in visual acuity compared with participants in the observation group (1 mg; risk ratio (RR): 5.27; 95% confidence interval (CI) 1.62 to 17.15; 4 mg RR 4.92; 95% CI 1.50 to 16.10) by the eighth-month follow-up examination, the average visual acuity decreased in all three groups. However, eyes treated with triamcinolone lost fewer letters than participants in the observation group at 8 months (1 mg mean difference (MD): 8.70 letters, 95% CI 1.86 to 15.54; 4 mg MD: 9.80 letters, 95% CI 3.32 to 16.28). A higher incidence of adverse events was noted with IVS therapy when compared with observation alone. As many as 20% to 35% of participants experienced an adverse event in the IVS groups compared with 8% of participants in the observation group of the SCORE study. The GENEVA investigators reported 63% in the treatment arm versus 43% in the observation arm experienced an adverse event. The most commonly encountered adverse events were elevated intraocular pressure, progression of cataracts, and retinal neovascularization. We graded the quality of evidence as low due to study limitations, imprecision of treatment estimates, and selective outcome reporting.

AUTHORS' CONCLUSIONS

The two RCTs reviewed herein provide insufficient evidence to determine the benefits of IVS for individuals with CRVO-ME. The improvement in visual acuity noted in the SCORE trial should be interpreted with caution as outcome data were missing for a large proportion of the observation group. Adverse events were observed more often with IVS treatment compared with observation/no treatment.

Outcomes of 195 consecutive patients undergoing 2-port pars plana vitrectomy with slit-lamp illumination system for posterior segment disease: a retrospective study

PURPOSE

The purpose of this study was to evaluate the safety and efficacy of 2-port 20-gauge pars plana vitrectomy with a slit-lamp illumination system in different vitreoretinal pathologies.

DESIGN

: Retrospective, consecutive, interventional case series.

METHODS

One hundred and ninety-five consecutive eyes of 195 patients underwent 20-gauge 2-port pars plana vitrectomy with a combination of slit-lamp illumination and a plano-concave contact lens, at the San Paolo Ophthalmology Center, from September 2005 through November 2007. Postoperative visual acuity at baseline and at 1, 3, and 6 months; intraoperative and postoperative complication rate; and surgical time were evaluated.

RESULTS

All patients completed 6 months of follow-up. The mean overall visual acuity was 0.74 ± 0.03 (mean ± SD) at baseline, improving to 0.56 ± 0.03 (P < 0.0001), 0.48 ± 0.03 (P < 0.0001), and 0.43 ± 0.03 (P < 0.0001) at 1, 3, and 6 months, respectively. No intraoperative complications occurred. Postoperative complications included retinal detachment in three patients, epiretinal membrane recurrence in three eyes, persistent macular hole in four eyes, and phthisis in one eye. Cataract formation was observed in 25 eyes. The total mean surgical time was 28.3 ± 10.1 minutes. No one had hypotony after the surgical procedure, and no cases of endophthalmitis were observed. Conversion to standard three-port vitrectomy was not necessary in any of the cases.

CONCLUSION

Two-port 20-gauge pars plana vitrectomy with slit-lamp illumination is a safe and effective procedure for posterior segment surgeries.

Techniques, rationale, and outcomes of internal limiting membrane peeling

BACKGROUND

The internal limiting membrane represents the structural interface between the retina and the vitreous and has been postulated to serve several essential functions. Recently, internal limiting membrane peeling has been used in the treatment of a variety of retinal disorders. We review the history, techniques, rationale, and outcomes of internal limiting membrane peeling.

METHODS

A review of the literature.

RESULTS

Internal limiting membrane peeling has been used to successfully treat a variety of retinal disorders including macular hole, epiretinal membrane, diabetic macular edema, retinal vein occlusion, and others.

CONCLUSION

Internal limiting membrane peeling may serve as an important component in the armamentarium of retinal surgery.

Long-term effects of vitrectomy and internal limiting membrane peeling for macular edema secondary to central retinal vein occlusion and hemiretinal vein occlusion

PURPOSE

The purpose of this study was to evaluate the long-term effects of vitrectomy and internal limiting membrane peeling for macular edema secondary to central retinal vein occlusion (CRVO) and hemiretinal vein occlusion (HRVO).

METHODS

Best-corrected visual acuity, central foveal thickness by optical coherence tomography, and fluorescein angiography were evaluated retrospectively in 20 patients (20 eyes). The mean follow-up time was 61.2 months. Pars plana vitrectomy and internal limiting membrane peeling using indocyanine green staining were performed in all patients.

RESULTS

Preoperative mean central foveal thickness of all 20 eyes decreased significantly by 6 months, and this reduction was maintained until 60 months. The mean central foveal thickness of the group with perfused type CRVO, ischemic type CRVO, and HRVO at 6 months significantly decreased from the preoperative value, and the significant reduction was maintained until 60 months. Best-corrected visual acuity of the perfused CRVO and HRVO groups tended to improve in contrast to the ischemic CRVO group postoperatively. Best-corrected visual acuity of the perfused CRVO group at 24 months or later was significantly improved from preoperative best-corrected visual acuity.

CONCLUSION

Pars plana vitrectomy with internal limiting membrane peeling in eyes with macular edema secondary to CRVO and HRVO produces an anatomical improvement, which persists up to 5 years, and a best-corrected visual acuity improvement, at least in perfused CRVO and HRVO.